Same-day test and treat for early detection and treatment of cervical cancer in LMICs
Authors: Rakiya Saidu, Imran Morhason-Bello
Journal: The Lancet Global Health (2022)

In 2020, 604 000 women were diagnosed with and 342 000 women died of cervical cancer, mostly in low-income and middle-income countries (LMICs),1International Agency for Research on CancerWHOCervix uteri.https://gco.iarc.fr/today/data/factsheets/cancers/23-Cervix-uteri-fact-sheet.pdfDate accessed: June 25, 2022Google Scholar making cervical cancer a public health problem in these settings. WHO recommends a 90–70–90 strategy for the elimination of cervical cancer by 2030: 90% of girls to be fully vaccinated with the human papillomavirus (HPV) vaccine by age 15 years; 70% of women screened with an HPV DNA test or other high-performance test by age 35 years, and again by age 45 years; 90% of women with cervical pre-cancer treated; and 90% of women with invasive cancer managed. For the HPV screening programme, WHO strongly recommends use of an HPV molecular test (self-collected or clinician-collected) as the primary screening test in all settings, with or without triage.2WHOWHO guideline for screening and treatment of cervical precancer lesions for cervical cancer prevention.second edition. World Health Organization, Geneva2021Google Scholar In The Lancet Global Health, Andrew Vallely and colleagues3Vallely AJB Saville M Badman SG et al.Point-of-care HPV DNA testing of self-collected specimens and same-day thermal ablation for the early detection and treatment of cervical pre-cancer in women in Papua New Guinea: a prospective, single-arm intervention trial (HPV-STAT).Lancet Glob Health. 2022; (published online July 22.)https://doi.org/10.1016/S2214-109X(22)00271-6Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar present the results of a prospective, single-arm intervention trial (HPV-STAT), which investigated point-of-care HPV DNA testing of self-collected specimens and same-day thermal ablation for the early detection and treatment of cervical pre-cancer among 4285 women in Papua New Guinea. The study reported that 647 (15·1%) women tested positive for one or more oncogenic HPV type, of whom 602 (93·0%) received same-day treatment with thermocoagulation. The algorithm used to detect high-grade squamous intraepithelial lesion (HSIL) or worse showed good sensitivity (85·4% [95% CI 81·0–89·6]) and specificity (89·6% [88·6–90·6]), with 98·9% negative predictive value (98·6–99·2) and 35·2% positive predictive value (31·6–39·0). This study is one of few that has evaluated a single-visit HPV screening and treatment strategy by use of a self-collected sample and a point-of-care HPV test in a real-world primary care setting in a LMIC. The findings support the feasibility of HPV-based screening and treatment approaches, as stated in WHO's newly revised guidelines on prevention of cervical cancer.2WHOWHO guideline for screening and treatment of cervical precancer lesions for cervical cancer prevention.second edition. World Health Organization, Geneva2021Google Scholar Furthermore, the trial showed that cervical cancer screening is feasible and achievable in LMICs by engaging middle-care health workers at the lowest health-care system level. The efficacy of self-collected samples for HPV tests was similar to a clinician-collected sample, and might reduce some current challenges in screening across LMICs, including cultural and religious barriers, and inadequate health-care workforce.4Arbyn M Smith SB Temin S Sultana F Castle P Detecting cervical precancer and reaching underscreened women by using HPV testing on self samples: updated meta-analyses.BMJ. 2018; 363k4823PubMed Google Scholar The high acceptability of self-collected specimens among participants, identification of HPV status, and decision to treat individuals with suspicious lesions in one visit makes this approach to HPV screening highly promising in LMICs with inadequate access to specialist care and poor record of follow-up. The authors explain that they used liquid-based cytology (LBC) as the diagnostic reference standard in their study to simulate a real-world setting; however, patients diagnosed with squamous cell carcinoma or adenocarcinoma by LBC should also be offered a colposcopy and histological confirmation of the disease. In the intervention trial, five (1·1%) of 463 HPV-negative women randomly selected to provide a LBC specimen had high-grade disease (three HSIL cases and two adenocarcinoma cases), which should have been confirmed by colposcopy and histological examination. Furthermore, missing this subset of women among the cohort of HPV-negative women might be a drawback to not offering gynaecological examination to HPV-negative women, particularly in women living with HIV. Vallely and colleagues3Vallely AJB Saville M Badman SG et al.Point-of-care HPV DNA testing of self-collected specimens and same-day thermal ablation for the early detection and treatment of cervical pre-cancer in women in Papua New Guinea: a prospective, single-arm intervention trial (HPV-STAT).Lancet Glob Health. 2022; (published online July 22.)https://doi.org/10.1016/S2214-109X(22)00271-6Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar promised to publish a separate paper on the screening programme's cost-effectiveness and requirements for health system implementation. It is imperative to report the logistical and other health system requirements of setting up this model in LMICs, where health systems are overburdened, strained, and stretched. Albeit beyond the scope of this Article,3Vallely AJB Saville M Badman SG et al.Point-of-care HPV DNA testing of self-collected specimens and same-day thermal ablation for the early detection and treatment of cervical pre-cancer in women in Papua New Guinea: a prospective, single-arm intervention trial (HPV-STAT).Lancet Glob Health. 2022; (published online July 22.)https://doi.org/10.1016/S2214-109X(22)00271-6Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar funding is an important area that still needs evaluation. In many LMICs, patients fund out-of-pocket payments for all aspects of their health care, including preventive services. Therefore, it is essential to evaluate the cost of this screening algorithm to the patient. Some studies from sub-Saharan Africa reported that introducing a fee for cervical screening programmes was acceptable among the study populations.5DeGregorio G Manga S Kiyang E et al.Implementing a fee-for-service cervical cancer screening and treatment program in Cameroon: challenges and opportunities.Oncologist. 2017; 22: 850-859Crossref PubMed Scopus (24) Google Scholar, 6Dim CC Onyedum CC Dim NR Chukwuka JC Cervical cancer screening among HIV-positive women in Nigeria: an assessment of use and willingness to pay in the absence of donor support.J Int Assoc Provid AIDS Care. 2015; 14: 241-244Crossref PubMed Scopus (9) Google Scholar Other innovations to reduce the cost of HPV-based screening programmes include the introduction of a new, low-cost, point-of-care HPV test, the re-designing and validation of which have been reported by Desai and colleagues.7Desai KT Adepiti CA Schiffman M et al.Redesign of a rapid, low-cost HPV typing assay to support risk-based cervical screening and management.Int J Cancer. 2022; (published online June 6.)https://doi.org/10.1002/ijc.34151Crossref Scopus (4) Google Scholar The most important conclusion from the trial by Vallely and colleagues3Vallely AJB Saville M Badman SG et al.Point-of-care HPV DNA testing of self-collected specimens and same-day thermal ablation for the early detection and treatment of cervical pre-cancer in women in Papua New Guinea: a prospective, single-arm intervention trial (HPV-STAT).Lancet Glob Health. 2022; (published online July 22.)https://doi.org/10.1016/S2214-109X(22)00271-6Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar is that implementation of a fully integrated point-of-care HPV self-collect, test, and treat strategy for same-day cancer screening and treatment is feasible and can be integrated into existing infrastructure at the primary health-care level across LMICs. We declare no competing interests. Point-of-care HPV DNA testing of self-collected specimens and same-day thermal ablation for the early detection and treatment of cervical pre-cancer in women in Papua New Guinea: a prospective, single-arm intervention trial (HPV-STAT)We conducted the first real-world evaluation of a fully integrated point-of-care HPV self-collect, test, and treat strategy for same-day cervical screening in a LMIC and found it to be effective, acceptable, and safe when implemented at scale in primary health-care facilities in Papua New Guinea. Our findings support the introduction and scale-up of HPV screening and treatment for the control and elimination of cervical cancer in LMICs, as recommended by WHO. Full-Text PDF Open Access